How Invasive is the Free Gracilis Muscle Flap? A Prospective Study on Donor Site Morbidity

Abstract

Background

Free gracilis muscle (GM) flaps represent a reliable workhorse procedure in the field of plastic and trauma surgery. However, only a small number of studies have examined this large group of patients regarding the morbidity of flap harvest. The aim of this prospective study was therefore to objectively investigate the morbidity of free GM flaps.

Methods

A control group (n = 100) without surgery was recruited to assess interindividual differences in strength and range of motion (ROM) in the hip and knee joint (dominant vs. nondominant side). Additionally, for 50 patients with free GM flap surgery, these parameters were assessed in an identical manner.

Results

The control group showed significant interindividual differences in strength for abduction and adduction in the hip joint when comparing the dominant to the nondominant side, but no significant differences in the ROM. GM flap harvest led to no significant differences in maximum force 20.3 (± 13.8) months after surgery in all parameters/movements that were assessed. However, the ROM for abduction in the ipsilateral hip joint was significantly reduced after surgery.

Conclusion

The GM flap has a low donor site morbidity and should therefore be considered as a first-line option for microsurgical reconstructive procedures. Moreover, the low morbidity is not affected by preexisting differences in strength when comparing the dominant to the nondominant side.

Keywords

gracilis muscle flap - donor site morbidity - free flap morbidity - strength and ROM after gracilis muscle flap

Note

This study was presented at the 53 Annual Congress of the German Society of Plastic Surgeons (DGPRAEC)/27 Annual Congress of the Society for German Aesthetic Surgery (VDAEPC) (September 14, 2023).

Authors' Contributions

Conceptualization (D.E., R.E.G., N.M., N.W.); data curation (M.Hi., M.He., N.W., T.N.); formal analysis (D.E., N.W., M.Hi., T.N.); funding acquisition (n/a), investigation (D.E., N.W., M.Hi.); methodology (M.Hi., N.M., M.He.); project administration (D.E., R.E.G., N.M., N.W.); resources. (D.E., R.E.G., N.W.); software (M.Hi., M.He.); supervision (D.E., R.E.G., N.W., T.N., N.M.); validation (R.E.G., D.E., N.W.); visualization (N.W., M.He., M.Hi.); writing—original draft (D.E., R.E.G., N.W., C.K., N.M., M.He., M.Hi.); writing—review and editing (D.E., R.E.G., N.W., T.N., N.M., M.Hi., M.He.).

Clinical Trial Statement

Ethical approval was provided by the local ethics committee (21-0475, LMU Munich, Germany).

Publication History

Received: 27 January 2025

Accepted: 31 May 2025

Article published online:
30 June 2025

• References

• 1 Calotta NA, Pedreira R, Deune EG. The gracilis free flap is a viable option for large extremity wounds. Ann Plast Surg 2018; 81 (03) 322-326
• 2 Franco MJ, Nicoson MC, Parikh RP, Tung TH. Lower extremity reconstruction with free gracilis flaps. J Reconstr Microsurg 2017; 33 (03) 218-224
• 3 Besset M, Penaud A, Quignon R, Bahe L, Brilhault J, Fouquet B. [Donor site morbidity after free gracilis muscle flap. Report of 32 cases]. Ann Chir Plast Esthet 2014; 59 (01) 53-60
• 4 Weitgasser L, Mahrhofer M, Schwaiger K. et al. Lessons learned from 30 years of transverse myocutaneous gracilis flap breast reconstruction: historical appraisal and review of the present literature and 300 cases. J Clin Med 2021; 10 (16) 3629
• 5 Daniel RK, Taylor GI. Distant transfer of an island flap by microvascular anastomoses. A clinical technique. Plast Reconstr Surg 1973; 52 (02) 111-117
• 6 Vranckx JJ, Misselyn D, Fabre G, Verhelle N, Heymans O, Van den hof B. The gracilis free muscle flap is more than just a “graceful” flap for lower-leg reconstruction. J Reconstr Microsurg 2004; 20 (02) 143-148
• 7 Oh TS, Lee HS, Hong JP. Diabetic foot reconstruction using free flaps increases 5-year-survival rate. J Plast Reconstr Aesthet Surg 2013; 66 (02) 243-250
• 8 Mitsala G, Varey AH, O'Neill JK, Chapman TW, Khan U. The distally pedicled gracilis flap for salvage of complex knee wounds. Injury 2014; 45 (11) 1776-1781
• 9 Engelhardt TO, Alghamdi HG, Wallmichrath J, Holzbach T, Dürr HR, Giunta RE. [Free gracilis flap for anatomic reconstruction after limb-sparing sarcoma resection]. Handchir Mikrochir Plast Chir 2015; 47 (02) 111-117
• 10 Oh TS, Kim HB, Choi JW, Jeong WS. Facial reanimation with masseter nerve-innervated free gracilis muscle transfer in established facial palsy patients. Arch Plast Surg 2019; 46 (02) 122-128
• 11 Koban KC, Kuhlmann C, Wachtel N. et al. To shrink or not to shrink? An objective assessment of free gracilis muscle volume change in lower-extremity defect reconstruction. J Clin Med 2024; 13 (16) 4811
• 12 Ehrl D, Niclas Broer P, Heidekrueger PI, Ninkovic M. Microsurgical forehead reconstruction. J Craniofac Surg 2017; 28 (01) 212-217
• 13 Siegwart LC, Bolbos A, Tapking C. et al. Safety and donor site morbidity of the transverse musculocutaneous gracilis (TMG) flap in autologous breast reconstruction-a systematic review and meta-analysis. J Surg Oncol 2021; 124 (04) 492-509
• 14 Vollbach F, Heitmann C, Fansa H. Autologe Brustrekonstruktion mit Gewebe von der Oberschenkelinnenseite. Senologie Zeitschrift Mammadiagnostik Therap 2014; 11 (04) 194-200
• 15 Fansa H, Schirmer S, Warnecke IC, Cervelli A, Frerichs O. The transverse myocutaneous gracilis muscle flap: a fast and reliable method for breast reconstruction. Plast Reconstr Surg 2008; 122 (05) 1326-1333
• 16 Pülzl P, Schoeller T, Kleewein K, Wechselberger G. Donor-site morbidity of the transverse musculocutaneous gracilis flap in autologous breast reconstruction: short-term and long-term results. Plast Reconstr Surg 2011; 128 (04) 233e-242e
• 17 Craggs B, Vanmierlo B, Zeltzer A, Buyl R, Haentjens P, Hamdi M. Donor-site morbidity following harvest of the transverse myocutaneous gracilis flap for breast reconstruction. Plast Reconstr Surg 2014; 134 (05) 682e-691e
• 18 Buntic RF, Horton KM, Brooks D, Althubaiti GA. Transverse upper gracilis flap as an alternative to abdominal tissue breast reconstruction: technique and modifications. Plast Reconstr Surg 2011; 128 (06) 607e-613e
• 19 Wechselberger G, Schoeller T. The transverse myocutaneous gracilis free flap: a valuable tissue source in autologous breast reconstruction. Plast Reconstr Surg 2004; 114 (01) 69-73
• 20 Siegwart LC, Bolbos A, Haug VF, Diehm YF, Kneser U, Kotsougiani-Fischer D. Donor site morbidity in unilateral and bilateral transverse musculocutaneous gracilis (TMG) flap breast reconstruction: sensation, function, aesthesis and patient-reported outcomes. J Clin Med 2021; 10 (21) 5066
• 21 Deutinger M, Kuzbari R, Paternostro-Sluga T. et al. Donor-site morbidity of the gracilis flap. Plast Reconstr Surg 1995; 95 (07) 1240-1244
• 22 Al Khaled NMS, Tsitsilonis S, Krapohl BD. Complex foot trauma: amputation vs. reconstruction - clinical evaluation and long-term quality of life. Ann Plast Reconstr Surg 2022; 6 (03) 7
• 23 Hertel R, Strebel N, Ganz R. Amputation versus reconstruction in traumatic defects of the leg: outcome and costs. J Orthop Trauma 1996; 10 (04) 223-229
• 24 Wechselberger G, Schubert HM, Schoeller T. [Versatility of the free gracilis muscle flap for coverage of soft-tissue defects]. Oper Orthop Traumatol 2008; 20 (02) 119-127
• 25 Loadpad product information; 2024
• 26 Schünke M, Schulte E, Schumacher U. Prometheus Allgemeine Anatomie und Bewegungssystem. Thieme; 2018
• 27 Soucie JM, Wang C, Forsyth A. et al; Hemophilia Treatment Center Network. Range of motion measurements: reference values and a database for comparison studies. Haemophilia 2011; 17 (03) 500-507
• 28 Pederson WC, Grome L. Microsurgical reconstruction of the lower extremity. Semin Plast Surg 2019; 33 (01) 54-58
• 29 Redett RJ, Robertson BC, Chang B, Girotto J, Vaughan T. Limb salvage of lower-extremity wounds using free gracilis muscle reconstruction. Plast Reconstr Surg 2000; 106 (07) 1507-1513
• 30 Salmi A, Tukiainen E, Härmä M, Asko-Seljavaara S. A prospective study of changes in muscle dimensions following free-muscle transfer measured by ultrasound and CT scanning. Plast Reconstr Surg 1996; 97 (07) 1443-1450
• 31 Oranges CM, Tremp M, Wang W. et al. Patient height, weight, BMI and age as predictors of gracilis muscle free-flap mass in lower extremity reconstruction. In Vivo 2018; 32 (03) 591-595
• 32 Syed A, Abdulrahman A, Mazen A. et al. Management of mangled extremities: upper vs lower limb differences. J Health Sci 2021; 2021: 8
• 33 Fricke A, Rassner M, Kiefer J, Bannasch H, Stark GB, Eisenhardt SU. Donor-site morbidity of free muscle and perforator flaps: comparison of the gracilis muscle flap and the anterolateral thigh flap. J Reconstr Microsurg 2017; 33 (07) 526-532
• 34 Lakhiani C, DeFazio MV, Han K, Falola R, Evans K. Donor-site morbidity following free tissue harvest from the thigh: a systematic review and pooled analysis of complications. J Reconstr Microsurg 2016; 32 (05) 342-357
• 35 Schellerer VS, Bartholomé L, Langheinrich MC. et al. Donor site morbidity of patients receiving vertical rectus abdominis myocutaneous flap for perineal, vaginal or inguinal reconstruction. World J Surg 2021; 45 (01) 132-140
• 36 Wachtel N, Giunta RE, Hellweg M. et al. What about the donor site morbidity - how invasive is the free latissimus dorsi flap?. Bone Jt Open 2024; 5 (12) 1114-1119
• 37 Heidekrueger PI, Ehrl D, Ninkovic M. et al. The spreaded gracilis flap revisited: comparing outcomes in lower limb reconstruction. Microsurgery 2017; 37 (08) 873-880